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TRICARE Policy Manual 6010.63-M, April 2021
Surgery
Chapter 4
Section 7.1
Oral Surgery
Issue Date:  October 8, 1986
Authority:  32 CFR 199.4(e)(10) and (g)(37)
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  
1.0  AMERICAN DENTAL ASSOCIATION (ADA) DENTAL NOMENCLATURE CODES
07285 - 07286, 07410 - 07420, 07430 - 07431, 07440 - 07441, 07450 - 07451, 07460 - 07461, 07465, 07480, 07490, 07520, 07530, 07540, 07550, 07560, 07610, 07620, 07630, 07640, 07650, 07660, 07670, 07680, 07710, 07720, 07730, 07740, 07750, 07760, 07770, 07780, 07810, 07820, 07830, 07840, 07860, 07870, 07910 - 07912, 07920, 07955, 07980 - 07983, 20605, 21010, 21050, 21060, 21141 - 21142, 21193 - 21198, 21215, 21240 - 21243, 21480, 21485, 21490, 21499, 29804.
2.0  DESCRIPTION
There are certain oral surgical procedures which are performed by both physicians and dentists, and which are essentially medical rather than dental care.
3.0  POLICY
3.1  The following are examples of procedures are considered to be in this category and are covered:
3.1.1  Excision of tumors and cysts of the jaws, cheeks, lips, tongue, roof and floor of the mouth, when such conditions require a pathological (histological) examination.
3.1.2  Surgical procedures required to correct accidental injuries of the jaws, cheeks, lips, tongue, roof and floor of the mouth.
3.1.3  Treatment of oral and/or facial cancer.
3.1.4  Treatment of fractures of facial bones.
3.1.5  External (extraoral) incision and drainage of cellulitis.
3.1.6  Surgery of accessory sinuses, salivary glands or ducts.
3.1.7  Surgical treatment of the temporal bone and the lower bone of the jaw.
3.1.7.1  The following are examples of conditions under which surgical treatment of the temporomandibular joint will be allowed:
•  Osteoarthritis
•  Trauma
•  Congenital causes, e.g., agenesis or hypoplastic condyle
•  Ankylosis
•  Tumors
•  Dislocations.
3.1.7.2  The contractor may use the current recommendations for Management of Patients with Temporomandibular Joint Implants published by the American Academy of Oral Maxillofacial Surgeons in their adjudication of claims involving temporomandibular joint surgery.
3.2  Any oral surgical procedure which falls within the cosmetic, reconstructive and/or plastic surgery definition is subject to the limitations and requirements set forth in 32 CFR 199.4(e)(8). Surgical correction of prognathism and micrognathism and congenital craniofacial anomalies (e.g., Treacher-Collins syndrome, hemifacial microsomia) is covered.
3.3  Oral surgical procedures for treatment of the following medical conditions are also covered:
3.3.1  Osteomyelitis.
3.3.2  Removal of a foreign body which is hazardous to the patient’s health, which is reaction-producing or complicates a primary medical condition.
3.3.3  Intrinsic and traumatic diseases of the temporomandibular joint which require surgery such as rheumatoid arthritis and osteoarthritis.
3.3.4  Mandibular bone grafts performed for other than orthodontia or dental support.
3.3.5  Surgical treatment of the temporomandibular joint.
3.3.6  The Therabite Jaw Motion System may be considered for cost-sharing as Durable Medical Equipment (DME).
4.0  EXCLUSIONS
4.1  Treatment of Temporomandibular Joint Syndrome, also known as Myofacial Pain Dysfunction Syndrome, occlusal equilibration and restorative occlusal rehabilitation are excluded from this category. See Chapter 8, Section 13.1.
4.2  Extraction of unerupted or partially erupted, malposed or impacted teeth, with or without the attached follicular or development tissues, are not covered oral surgery procedures except when the care is indicated in preparation for, or as a result of, dental trauma caused by the medically necessary treatment of an injury or illness.
4.3  Surgical preparation of the mouth for dentures except for adjunctive dental care (Current Procedural Terminology (CPT) codes 40840 - 40845).
4.4  Mandibular staple implants are not covered because their primary purpose is to prepare the mouth for dentures.
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